Cases & Commentaries

Following reconstructive surgery to her hand, a woman suffers sudden cardiopulmonary arrest. After successful resuscitation, further review revealed that she had a pulmonary embolism and that she had received no venous thromboembolism prophylaxis.

Cases & Commentaries

A woman with a fractured right foot receives spinal anesthesia and nearly has surgery for trimalleolar fracture and dislocation of the left ankle. Only immediately prior to surgery did the team realize that the x-ray was not hers.

Cases & Commentaries

Following elective surgery, a man with benign prostatic hypertrophy began having trouble with urination. Delay in addressing this issue caused discomfort and the need for catheterization and antibiotics.

Cases & Commentaries

An elderly woman underwent knee replacement, during which her airway was maintained with a laryngeal mask airway. However, she developed a fever and fullness in her neck, which a CT scan revealed to be retropharyngeal and mediastinal abscesses.

Cases & Commentaries

Based on preoperative discussions, a patient undergoing knee replacement expected to receive spinal anesthesia; however, general anesthesia was administered, and the records did not note or explain this change. The patient suffered an unusual complication.

Cases & Commentaries

Eager to have his knee replaced, an active older patient travels overseas for the surgery. At home 2 weeks later, he develops acute pain and swelling in his knee. A local orthopedic surgeon's office tells him to contact his operating physician, nearly 5000 miles away.

Cases & Commentaries

Following an appendectomy, an elderly man continued to have right lower quadrant pain. Reviewing the specimen removed during the surgery, the pathologist found no appendiceal tissue. The patient was emergently taken back to the OR, and the appendix was located and removed.

Cases & Commentaries

Unaware of the plan to remove a spinal drain under general anesthesia, the on-call anesthesiologist attempted to remove it while the patient was awake. The catheter broke, leaving a portion inside the spinal canal. Consequently, a neurosurgeon had to surgically remove the catheter.

Cases & Commentaries

An elderly woman with severe abdominal pain was admitted for an emergency laparotomy for presumed small bowel obstruction. Shortly after induction of anesthesia, her heart stopped. She was resuscitated and transferred to the intensive care unit, where she died the next morning. The review committee felt this case represented a diagnostic error, which led to unnecessary surgery and a preventable death.

Cases & Commentaries

Following general anesthesia for hip repair surgery, an elderly woman with a history of hypertension and obesity developed hypercarbic respiratory failure and was reintubated in the recovery unit. Providers felt the patient had undiagnosed obstructive sleep apnea and questioned whether obese patients undergoing anesthesia should receive formal preoperative screening for it.

Cases & Commentaries

Following outpatient laparoscopic surgery to repair an inguinal hernia, a man with no significant past medical history had high levels of pain at the surgical site and was admitted to the hospital. With sustained pain on postoperative day 3, the patient developed tachycardia with abdominal distension and a low-grade fever. A CT scan revealed a bowel perforation, which required surgery and a lengthy ICU stay due to septicemia.

Perspectives on Safety > Perspective

Over the last decade, surgical operations and interventional procedures have been performed increasingly in offices with the administration of office-based anesthesia (OBA).(1) Economic considerations and convenience have driven this increase. Schultz...

Journal Article > Study

This study described findings from 35 interviews with parents about perceptions of error risk during their child's surgery. Through qualitative analysis, the investigators identified 12 themes from the interview transcripts. The themes were divided into "worries or fears" and "reassuring considerations," with detailed examples of each provided in the discussion. Strategies to address the patient-centered approach are offered along with their relation to risk management goals. The authors conclude that understanding parents' expectations and vulnerability plays an essential role when communicating risks in these settings.

Journal Article > Study

The investigators observed surgeons participating in three skills tests, one of which involved error detection. Results indicate that the ability to recognize error served as a predictor of the technical skills exhibited while accomplishing the other assigned tasks.

Journal Article > Study

The authors analyzed surgical adverse events to assess the occurrence, cause, patient impact, and preventability of the incidents. They found that the surgical events increased average lengths of stay by 9.9 days and have a lower level of preventability than other types of adverse events.

Based on prior review articles, the use of perioperative beta blockers in non-cardiac surgery has become a widely recommended patient safety practice. This review, which included a larger sample of more recent literature than prior studies, found that, while beta blockers slightly reduced adverse cardiovascular outcomes (including death), this reduction came at the cost of an increased risk for treatment-requiring hypotension and bradycardia. The authors recommend that enthusiasm for the use of perioperative beta blockers be tempered, and that additional studies be conducted to help inform this important debate.

This study discusses the practical use of health care failure mode and effects analysis (HFMEA) by presenting a real case example of this qualitative methodology. Discussion focuses on creating an initial process flow diagram and how information obtained through interviews adds necessary detail to those flow charts. The mapped-out process then leads to identification of potential failures and the development of strategies to address them. The authors conclude that HFMEA may allow systems to uncover latent errors beyond those discovered with root cause analyses or quantitative techniques.

Journal Article > Study

This AHRQ-funded case-control study used physicians' clinical judgment about flagged complications to generate potential deficiencies in the quality of care. Compiling data for more than 1000 Medicare beneficiaries from acute-care hospitals, investigators captured cases with a documented surgical or medical complication along with matched controls without such complications. The authors report that potential quality problems were identified at much higher rates in the flagged cases, but the judgments made about quality were affected by many circumstances, such as the complexity of a given case. Therefore, while subjectivity in physician case review exists, this study offers a potential strategy for selecting cases that might increase the yield in such interpretations of quality.

Based on a recommended clinical indicator in surgical patients, this study used a cohort of more than 44,000 to identify 200 patients who experienced an unplanned postoperative admission to an intensive care unit. Investigators discovered that more than half of these patients experienced at least one incident or near miss and that their mortality rates and lengths of stay were significantly increased, while their likelihood for discharge was decreased. The authors conclude that this methodology may serve as an important tool to promote patient safety by generating data that do not require complex risk-adjustment models and rely on more easily obtainable information from a medical chart.

The researchers compared postoperative intensive care unit admission records at one hospital to track differences between surgery and anesthesia preoperative medication histories. They found that 73% had at least one discrepancy.

Using closed malpractice claims from a previously described database, this study discovered significant patient injury associated with monitored anesthesia care (MAC) and a liability profile similar to that of general anesthesia. Investigators performed a detailed analysis of more than 120 MAC claims, compared them with those of general and regional anesthesia, and report on the claim characteristics. MAC claims involved older and more ill patients, with respiratory depression being the most frequent occurrence leading to patient injuries. The authors conclude that more than half of the claims would be preventable with improved monitoring strategies.

Journal Article > Study

This study determined that patients with complaints during a surgical admission were more likely to experience a surgical complication than those patients without complaints. Investigators conducted a retrospective analysis of nearly 17,000 surgical admissions using administrative data to identify complications while simultaneously capturing unsolicited patient complaints. While the findings suggest a correlation, the absolute number of patient complaints was low and nature of patient complaints varied (eg, due to poor clinical outcome versus dissatisfaction with a provider), making further interpretation difficult.

Journal Article > Review

The author reviews the epidemiology of surgical adverse events from major epidemiologic studies and discusses the need for a systems approach to preventing wrong-site surgery with particular emphasis on spinal surgery.

The investigators sought to identify the types of adverse events (AE) that can take place during spinal surgery. By assessing the relationship of AEs to complications, they believe their findings will support the development of prevention activities to improve patient safety.

The researchers describe their use of radiofrequency identification to locate retained objects after surgery. They found that the handheld wand, if used correctly, was 100% accurate in detecting retained sponges.

Journal Article > Study

The authors identified 258 malpractice claims from 4 liability insurance companies where patients were harmed due to surgical error and reviewed these cases to determine the relative contribution of 17 "human factors" to the adverse event. Both individual and system factors contributed to errors, classified as cognitive errors, lack of technical competence or knowledge, communication breakdowns, patient-related factors, and others. The cases resulted in significant harm: 23% of the patients died, and 65% suffered disabling injuries. Most cases involved more than one clinician, and 31% involved multiple phases of care (eg, intraoperative and perioperative). The authors recommend researching methods to improve outcomes for less experienced surgical teams and reducing communication errors through structured signout and communication systems.

Journal Article > Study

This cohort study examined the relationship between surgery start time and anesthetic adverse events (AEs) using a large database of anesthesia procedures at an academic medical center. The incidence of AEs was increased for surgical procedures starting in the late afternoon compared with those starting in the morning. The authors hypothesize that this finding could reflect fatigue (as demonstrated in a prior simulation study) or problems with care transitions; however, they were not able to directly measure case load or composition of the care team. Moreover, for most AEs, the authors could not determine whether patients were harmed or whether the error was preventable.

Journal Article > Study

Although instances of wrong-site, wrong-procedure, and wrong-patient adverse events (WSPEs) have been widely publicized, the true incidence of such errors remains unclear. A prior study indicated a rate of approximately 1 case per 112,000 surgeries, but WSPEs may occur in the outpatient setting or in ambulatory surgery as well. In this study, the authors reviewed four databases to determine the incidence of all WSPEs, including procedures performed outside the operating room. Data from both mandatory and voluntary reporting systems indicates that approximately 1300 to 2700 WSPEs occur yearly, with many occurring during outpatient procedures. The authors argue that all WSPEs should be considered preventable, and recommend reporting and prevention standards for reducing such errors.

Journal Article > Study

The authors describe developing an observational assessment of the impact of teamwork on surgical outcomes. Initial findings show that the tool helped identify gaps in performance areas such as equipment double-checks and verbal procedural confirmation.

The authors describe the systematic analysis of an incident involving inappropriate use of a medical device and discuss how their process for understanding and resolving the problem supported the safety culture in their organization.

Journal Article > Review

The authors analyzed the literature to identify important components of safe surgical care and determine what research is needed to deepen the understanding of how human error affects surgical practice.